The experiences of homecare workers in navigating the COVID-19 pandemic: a protocol for a qualitative study

Background: Globally, there have been over 400 million confirmed cases of coronavirus disease 2019 (COVID–19), including over 6 million deaths, reported to the World Health Organization. Older adults have been disproportionally affected by COVID-19 in terms of morbidity and mortality. Homecare workers continue to play a key role in supporting vulnerable people to live in their own homes. Unlike other health professionals, whose interactions with patients are relatively brief, homecare workers sometimes spend hours with clients assisting with caregiving and functional tasks. In addition, these workers frequently provide companionship and emotional support. The COVID-19 pandemic has resulted in many challenges to this caregiving role given the risk of virus transmission to both clients and homecare workers in the community. Despite the vital role homecare workers have played, qualitative research exploring perspectives of homecare workers experiences’ of providing help and care to older adults during the pandemic is sparse. This study aims to explore the experiences of homecare workers in navigating the COVID-19 pandemic. Methods: A qualitative interpretative approach will be applied in this study through the facilitation of focus groups with homecare workers. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines will be used to standardise the conduct and reporting of the research. Homecare workers will be recruited from a provider of homecare services in the Mid-West of Ireland (Clarecare) by a gatekeeper. Focus groups will be transcribed and analysed using a reflexive thematic approach supported by the use of NVIVO software package (Version 12). Conclusion: This study represents a necessary first step in the development of an evidence base for clinical, education, and support needs of homecare workers.


Introduction
Increased life expectancy, multimorbidity and population growth have led to an increase in the number of people who require homecare assistance to meet their health needs (Martínez-Linares et al., 2020). The homecare sector is projected to grow significantly as society ages and care shifts from the acute care to the home environment (Leverton et al., 2021). As the demand on the homecare sector increases, the sector is increasingly under pressure to retain experienced staff, and frequent turnover can negatively impact on the quality, safety and continuity of care, particularly among vulnerable older adults ( . It has been known to be called a "diaphanous profession" or the "invisible welfare" due to the lack of recognition these workers receive for their job (Gazzaroli et al., 2020). In a recent study, Belgian homecare workers described feeling "squeezed like a lemon" due to the poor working conditions and the demanding nature of the job (Bensliman et al., 2021). In Norway, homecare workers reported being exposed to occupational hazards and physically demanding tasks which affected their safety, health and wellbeing (Gronoset Grasmo et al., 2021). In the UK, qualitative semi-structured interviews were held with 29 homecare workers providing care to people with dementia at end of life and 13 homecare managers. The homecare workers felt "emotionally drained, underprepared and overwhelmed". It was found that there is a need for development of models to support homecare workers and alleviate the emotional, interpersonal and practical burdens (Yeh et al., 2019, pp 352-359). A further UK study explored the training and support needs of homecare workers and reinforced the need for the development of a professional framework, incorporating training for homecare workers as well as ongoing practical and emotional support (Leverton et al., 2021).
In Ireland, a home support service is provided to older adults who wish to remain in their own home. This service was previously known as the Home Help Service or Home Care Package. The individuals caring for older adults are known as homecare workers, home carers, home help or home support (Home Support Services, 2022). In 2018, the Institute of Public Health in Ireland conducted a report to improve home care services in Ireland (The Institute of Public Health, 2018). This report highlighted that home carer workers are largely underpaid; employment is often insecure and opportunities for advancement are low. It was recommended that homecare be defined, and specific services should be addressed i.e., sociopsychological needs, loneliness, companionship and domestic services. In addition, it was recommended that a standardised policy framework may be important to implement, however, there must be scope for service flexibility.
Homecare workers have played a key role in supporting community dwelling older adults to live in their own homes and communities during the coronavirus disease 2019 (COVID-19) pandemic. The pandemic has led to 400 million reported cases and 6 million deaths globally (WHO, 2022). Unlike other health professionals, whose interactions with patients are relatively brief, homecare workers sometimes spend hours with clients assisting with caregiving and functional tasks. In addition, these workers frequently provide companionship and emotional support. The COVID-19 pandemic has resulted in many challenges to this caregiving role, given the risk of virus transmission to both clients and homecare workers in the community. A US study found the COVID-19 pandemic led to deterioration of clients' health due to a lack of social supports compared to those available pre pandemic, with this paucity of support networks found to impact mental and physical health, particularly in the role of homecare workers (Bell et al., 2022). These findings echoed a study exploring COVID-19 challenges amongst home based palliative care workers, with staff driven to provide care throughout COVID-19 and its associated risks due to a strong sense of responsibility towards their clients and colleagues, identifying their role as one of the few stable supports for clients and families (Franchini et al., 2021). Insights for an EU study which explored homecare workers' training and learning experiences during COVID-19 highlighted the challenges faced by staff, while also acknowledging homecare workers' adaptability through the learning of new practices, skills and approaches (Malmgren Fänge et al., 2022).
Despite the recognition of higher mortality rates among older adults and higher overall rates of disease among nursing home staff, little remains known about the risks and experiences of workers who provide help and care to older adults who live at home (Allison et al., 2020; Weeks et al., 2021). The protocol for this qualitative study explores the experiences of homecare workers in navigating the COVID-19 pandemic.

Protocol
Design A qualitative interpretative design will be adopted to explore in-depth the experiences of homecare workers during the COVID-19 pandemic. This study design was chosen as it is effective for intervention development in the way it allows the focus of the study to be on the homecare workers' experiences. This approach is useful when collecting homecare workers' views on this specific topic. This study will adhere to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist for interviews and focus groups to ensure rigour and comprehensiveness (Tong et al., 2007).

Ethics
Ethical approval was granted from the Research Ethics Committee of the Faculty of Education and Health Sciences, University of Limerick (Ref: 2021_12_18_EHS). Date of grant approval 22/10/21. Written consent forms, along with study information sheets, will be distributed among participants. The study information sheets have been approved by the ethics committee. The protocol on Dealing with Distressed participants will be adhered to should sensitive topics be brought up (Moynan et al., 2022b).

Recruitment and participants
Homecare workers will be purposively recruited from Clarecare. Clarecare operates a homecare service in the Mid-West of Ireland (mainly in County Clare) on behalf of the national Health Service Executive (HSE). This service mainly provides homecare assistance to older people. The organisation currently employs 279 homecare workers, providing care to adults aged ≥65 years in the MidWest.
Homecare staff will be recruited through an email invitation from a gatekeeper in Clarecare. Inclusion and exclusion criteria will be developed to support methodological rigour. Inclusion criteria: A) Adults aged ≥18 years; B) Homecare worker has the capacity and willingness to provide informed consent; C) Homecare worker working with older adults ≥65 years. Exclusion criteria: A) Homecare worker exclusively working with younger populations (<65 years); B) Inability to communicate sufficiently in English to participate in focus groups.
When prospective participants express interest in participating, the research team will arrange a follow up phone call a minimum of two days later to allow time to consider participating. It is anticipated that three focus groups will be facilitated, with 6-8 homecare workers participating in each focus group, providing insights from homecare workers across five geographic areas. 6 -8 homecare workers in each focus group is in line with supporting literature on the facilitation of focus groups which reflects the importance of a smaller group to facilitate effective engagement and allow opportunities for participation amongst participants (Braun & Clarke, 2021; Kreuger & Casey, 2000).

Data collection
Study researchers developed a semi-structured focus group guide which consists of three content areas: participants' experiences of providing homecare since the COVID-19 outbreak, challenges participants have faced since the COVID-19 outbreak, what has supported participants since the COVID-19 outbreak. The focus group guide consists of open-ended questions and related prompts. The focus groups will take place in person in mid-June in 3 Clarecare bases -Killaloe, Kilkee and Ennis, over a period of 3 days. See extended data for the focus group guide (Moynan et al., 2022a).

Data analysis
Focus groups will be digitally audio-recorded, transcribed and exported to NVivo (Version 12.6.0). Each participant will get their own unique number. The participants' details and their associated numbers will be kept on a password-protected Excel file. The transcribed focus group data will be analysed following a reflexive thematic approach (Braun & Clarke, 2021) through the identification and analysis of themes from the focus group data (Byrne, 2021). Initially a focus group transcript will be coded by two independent researchers (EM and CF) and subsequently discussed to explore different perspectives and insights from coders, as opposed to seeking consensus. All data will then be coded by one researcher. The six steps of thematic analysis described by Braun and Clarke will be followed (Braun & Clarke, 2021; Braun & Clarke, 2006), which will be used as a guide, with an emphasis on the flexible nature of these steps in line with the reflective thematic analysis approach utilised. The first step, involving data familiarisation, will be achieved through analysis following transcription and reading of all data. The second step, involving generating initial codes systematically across the data set, will have a particular focus on the research question. In the third step, overlapping codes will be identified and preliminary themes will be identified. In the fourth step, these themes will be reviewed with the research supervisor and in the fifth step they will be defined and named. The final step involving preparation of the manuscript with quotes from the focus group data will be completed to illustrate the themes identified.

Dissemination
Subsequent to the analysis stage, key themes and a summary of findings will be shared with participants. Abstracts will be submitted to relevant national and international conferences. Locally, the study results will be shared with management and staff at Clarecare.

Study status
Data collection is expected to take place mid-June 2022, with transcription of interviews and data analysis to be completed late June 2022.

Conclusion
To the authors' knowledge, no studies have been conducted to explore the experiences and perspectives of homecare workers during the COVID-19 pandemic. It is anticipated that understanding and exploring their experiences will assist in the development of interventions that may serve to improve working conditions and supports for homecare workers.

Underlying data
No underlying data are associate with this article. Is the rationale for, and objectives of, the study clearly described? Yes

Are sufficient details of the methods provided to allow replication by others? Yes
Are the datasets clearly presented in a useable and accessible format? Not applicable approach to coding is similar for both designs, but there is an additional level of interpretation based on the context in ID.
In an ideal world, it is better to have time between FG to allow for preliminary coding and to identify new emerging topics that should be explored in subsequent FG interviews. ○ Will the authors offer the opportunity for 1:1 or telephone interviews in the event a person would like to be involved but cannot attend or is afraid to speak openly given they are interviewed on their employer's premises -these are private, not public workers -it is worth considering how this risk can be managed.

Abstract
A minor point: "Unlike other health professionals", home care workers don't hold a professional registration -so query 'health care workers'.
○ Define who you mean by home care workers -there are multiple terms used for this workforce, clarify it excludes community nurses, PHN, and volunteer visitors.
○ "A qualitative interpretative approach" -This is not a qualitative design? Interpretive descriptive or thematic analysis -be more specific about design.

Background
Define home care work (see comment in the abstract).
○ "Communities during the coronavirus disease 2019" -'Communities' does not seem to make sense in the context of this sentence.
○ "A US study found the COVID-19 pandemic led to deterioration of clients' health due to a lack of social supports compared to those available pre pandemic, with this paucity of support networks found to impact mental and physical health, particularly in the role of homecare workers (Bell et al., 2022)". Clarify is it the client or home care workers whose physical and mental health deteriorated.

Design
Aim: the aim is buried in the design sentence, state the aim more clearly.

○
The aim of the study is: -also useful to expand on objectives -for example, later you justify the design as an approach to intervention design, so is an objective to identify learning and emotional support needs?
○ "A qualitative interpretative design will be adopted to explore in-depth the experiences of homecare workers during the COVID-19 pandemic." -'A qualitative interpretative design', this is not a design? Descriptive interpretive or descriptive phenomenon or thematic analysisneed to reference design.
○ "This study design was chosen as it is effective for intervention development in the way it allows the focus of the study to be on the homecare workers' experiences." -Need to reference. As a ○ protocol, include more detail on the distinguishing features of the design you have chosen supported with references.
"homecare workers across five geographic areas" -How are you defining a geographical region, the provider operates in one county -clarify.

Inclusion criteria
Is there a minimum duration of working as a home care worker? ○ Sample size: outline the role of data saturation in determining sample size.

○
Outline how the topic guide was developed -the broad questions.

○
Your design seems to be thematic analysis rather than interpretative descriptive -thematic analysis is both a design and approach to coding. Need for further clarification here.

○
Clarify if interviews and analysis will be undertaken concurrently with the opportunity to modify or explore new concepts in later interviews or will the interviews all be completed prior to iterative analysis? ○ Will there be any attempt to validate the themes with the homecare workers? Clarify if this is part of the analysis stage or just post-analysis dissemination.

○
To the authors' knowledge, no studies have been conducted to explore the experiences and perspectives of homecare workers during the COVID-19 pandemic -is this in the Irish context? The background suggested there is international data.